Transcatheter Versus Surgical Aortic Valve Replacement in Solid Organ Transplant Recipients and Liver Cirrhosis: A Propensity Matched Analysis of National Readmission Data.

BACKGROUND: Transcatheter Aortic Valve Replacement (TAVR) continues to grow in the US. There is limited data on solid organ transplant (SOT) recipients and liver cirrhosis patients undergoing aortic valve replacement (AVR). Our study aims to evaluate outcomes in these populations. METHODS: Using the national readmission database (2016-2020), We identified SOT recipients and liver cirrhosis patients without prior liver transplants admitted for severe aortic stenosis and underwent either TAVR or surgical aortic replacement (SAVR). We used multivariable regression for adjusted analysis and the Propensity Score Matching model, implementing complete Mahalanobis Distance Matching within the Propensity Score Caliper (0.2) to match TAVR and SAVR cohorts for outcomes. RESULTS: Among 3,394 hospitalizations for (AVR) in SOT recipients, 2,181 underwent TAVR, and 1,213 underwent SAVR. On propensity-matched analysis, SAVR compared to TAVR was associated with higher adverse events, including in-hospital mortality (5.2% vs. 1.1%, adjusted odds ratio (aOR): 4.49, p < 0.001), acute kidney injury (AKI) (43.7% vs. 10.2%, p < 0.001), cardiogenic shock (9.0% vs. 1.6%, p < 0.001), sudden cardiac arrest (15.9 vs. 6.0%, p < 0.001), major adverse cardiac and cerebrovascular events (MACCE) (28% vs. 10.4%, p < 0.001) and net adverse events (72.8 vs. 37.6%, p < 0.001). A higher median length of stay (LOS) (10 vs. 2 days, p < 0.001) and adjusted cost ($80,842 vs $57,014, p < 0.001) were also observed. The readmission rates were the same for both cohorts after a six-month follow-up. Similarly, among 14,763 hospitalizations for AVR in liver cirrhosis, 7,109 underwent TAVR, and 7,654 underwent SAVR. In propensity-matched cohorts (N=2,341), SAVR was found to be associated with higher adverse events, including in-hospital mortality (19.8% vs. 10%, aOR: 5.52), stroke (6.7% vs. 2%), AKI (67.7% vs. 30.3%), cardiogenic shock (41.9% vs. 19.9%), sudden cardiac arrest (31.8% vs. 13.2%, aOR: 2.89), MACCE (66.2% vs. 35.7%) and net adverse events (86% vs. 59.5%) [p-value < 0.001]. A higher median LOS (16 vs. 3 days) and cost ($500,218 vs $263,383) were also observed [p-value < 0.001]. However, the rate of readmissions at 30-day (9% vs. 11.1%) and 180-day intervals (33.4% vs. 39.8%) were lower for the SAVR cohort [p-value<0.05]. CONCLUSION: In solid organ transplant recipients and liver cirrhosis patients, SAVR is associated with higher short-term mortality, adverse events, and healthcare burden as compared to TAVR. TAVR is a relatively safer alternative to SAVR in these patient populations, although further studies are warranted to compare the long-term outcomes.

Transcatheter aortic valve replacement outcomes in patients with high gradient versus low ejection fraction low gradient severe aortic stenosis: A meta-analysis of randomized controlled trials.

BACKGROUND: The outcome of Low Flow-Low Gradient (LF-LG) severe aortic stenosis (AS) patients who underwent Transcatheter Aortic Valve Replacement (TAVR) procedure is not well defined. We conducted a systematic review of the literature to compare the outcomes of TAVR in LF-LG AS patients to the more traditional high gradient (HG) aortic stenosis. METHODS: We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We are presenting the data using risk ratios (95 % confidence intervals) and measuring heterogeneity using Higgins' I2 index. RESULTS: Our analysis included 4380 patients with 3425 HG patients and 955 LF-LG patients from 6 cohort (5 retrospective and 1 prospective) studies. When compared to LFLG; TAVR was associated with significantly lower 30 days mortality in HG patients (5.1 % vs 7.4 %; relative risk [RR]: 0.55; 95 % confidence interval [CI]: 0.35 to 0.86; p < 0.01). Similar findings were also observed in 12-month cardiovascular (CV) mortality (5.5 % vs. 10.4 %; RR: 0.47; 95 % CI: 0.38 to 0.60; p < 0.01 and 12-month all-cause mortality (15.9 % vs 20.9 %; RR: 0.70; 95 % CI: 0.49 to 1.00; p < 0.05). There was no significant difference in myocardial infarction (MI) after TAVR between HG and LF-LG at 30 days (0.16 % vs. 0.95 %; p < 0.09) or 12 months (0.43 % vs. 0.95 %; p = 0.20). Similarly, there was no difference in stroke rates at 30 days (2.9 % vs. 2.86 %) or at 12 months (3.6 % vs. 3.06 %). CONCLUSIONS AND RELEVANCE: Patients with LF-LG severe AS who underwent TAVR had worse 1-year all-cause mortality, 30-day all-cause, and 1-year CV mortality when compared to TAVR in HG severe AS. There was no difference in MI or stroke rates. Therefore, with heart team discussion and informed patient decision regarding the risk and benefit, TAVR would still offer better outcomes in LFLG AS compared to conservative medical management.

Transcatheter aortic valve replacement with corevalve self-expanding bioprosthesis: Clinical and durability data up to 12 years.

BACKGROUND AND AIMS: Transcatheter aortic valve replacement (TAVR) determined a paradigm shift in the treatment of patients with severe symptomatic aortic stenosis but data on very long-term durability are lacking. We sought to evaluate the clinical and hemodynamic outcomes of the CoreValve porcine pericardial self-expanding bioprosthesis at 12-year follow-up. METHODS: 882 inoperable or high-risk patients were treated with the CoreValve bioprosthesis in 8 Italian high-volume centers between 2007 and 2011. The endpoints were 12-year all-cause and cardiovascular mortality, and Cumulative Incidence Functions (CIFs) for severe Structural Valve Deterioration (SVD), Bioprosthetic Valve Dysfunction (BVD), Bioprosthetic Valve Failure (BVF), and severe Hemodynamic Valve Deterioration (HVD). VARC-3 definitions were applied. RESULTS: Baseline characteristics included a mean age of 83 ± 6 years, and NYHA class III or IV in 76.3 % of patients. The actuarial risk of death at 12 years after TAVR was 95.5 % (CI 93.5 %- 97.1 %). The actual risk of cardiovascular death, weighted against the risk of non-cardiac death at 12 years was 23.9 % (21.0 %-26.8 %). The 12-year actual risk of BVD was 7.0 % (5.3 %-8.9 %), of SVD was 3.6 % (2.5 %-5.2 %), of BVF was 3.12 % (2.02 %-4.57 %), and of severe HVD was 1.7 % (0.9 %-2.9 %). Mean transaortic gradient significantly decreased after the procedure (52 ± 15 mmHg vs 9 ± 5 mmHg, p < 0.001), and remained stable up to 12 years (12 ± 4 mmHg, P = 0.08 vs. discharge). CONCLUSIONS: The first-generation CoreValve bioprosthesis showed reassuring clinical and hemodynamic performance at 12-year follow-up.

The Heart Team during the Pandemic: A Case Report of Bio-Prosthesis Degeneration Treated with Valve in Valve Implantation.

The pandemic changed the type of patients. The concept of "patient at the center" became concrete. The execution of simple consultancy was overcome to create effective collaboration and fruitful exchanges between specialists. The "Heart Team" model is on increasing affirmation. The TEAM-BASED approach in the cardiology field is successfully used in patients suffering from ischemic heart disease and valvulopathies for the choice of possible treatments. Degenerative type Sao is the most frequent valvulopathy among the valvulopathies in Western countries and its incidence is correlated with age. In high-risk patients, percutaneous valve replacement (transcatheter aortic valve implantation) is the most valid therapeutic option. The implantation of biological prostheses raises the problem of both degeneration and dysfunction of the prosthesis itself over time in subjects of advanced age and with comorbidities. In this scenario, valve-in-valve (VinV) is a valid therapeutic alternative in high-risk patients. A clinical case of aortic prosthetic degeneration, as an outcome of endocarditis, treated with VinV is presented. The therapeutic decision was made by an "Electronic Heart Team" which represents a further evolution of the treatment pathways and reduces the distance between the specialists in "Hub" Centers and the "Spoke" center.

Rates, predictors, and causes of readmission after transcatheter aortic valve replacement in patients with chronic kidney disease.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is a revolutionary procedure for severe aortic stenosis. The coexistence of chronic kidney disease (CKD) and TAVR introduces a challenge that significantly impacts patient outcomes. AIM: To define readmission rates, predictors, and causes after TAVR procedure in CKD stage 1-4 patients. METHODS: We used the national readmission database 2018 and 2020 to look into readmission rates, causes and predictors after TAVR procedure in patients with CKD stage 1-4. RESULTS: Out of 24758 who underwent TAVR and had CKD, 7892 (32.4%) patients were readmitted within 90 days, and had higher adjusted odds of being females (adjusted odds ratio: 1.17, 95%CI: 1.02-1.31, P = 0.02) with longer length of hospital stay > 6 days, and more comorbidities including but not limited to diabetes mellitus, anemia, and congestive heart failure (CHF). CONCLUSION: Most common causes of readmission included CHF (18.0%), sepsis, and complete atrioventricular block. Controlling readmission predictors with very close follow-up is warranted to prevent such high rate of readmission.

Spontaneous calcified cerebral emboli: a comprehensive review and proposed diagnostic criteria.

Spontaneous calcified cerebral emboli (SCCE) secondary to aortic valve calcification are a rare and underreported cause of acute ischaemic stroke. Only five cases of SCCE secondary to bicuspid aortic valve calcification have been reported in the literature. This review includes a unique case example of acute ischaemic stroke secondary to SCCE, as the first manifestation of a calcified bicuspid aortic valve. This is the first clinical case of calcified cerebral emboli (CCE) associated with borderzone infarction ('cortical ribbon sign'). Whilst previously assumed that most CCE are secondary to iatrogenic causes, recent literature suggests the majority of CCE are spontaneous and clinically silent. Despite CT imaging widely considered the 'gold standard' for diagnosis, CCE are frequently misdiagnosed and missed entirely. Misdiagnosis of CCE may have catastrophic consequences due to the high risk of recurrence and missed opportunity to prevent neurological disability and death. This review presents a revised CCE diagnostic criteria, using evidence that has emerged over the last decade to create both Compulsory (Major) and Supporting (Minor) criteria. Current CCE management is not evidence based and remains largely speculative. SCCE may be the first manifestation of cardiac or vascular disease and diagnosis should trigger aggressive treatment of emboligenic sources. Future epidemiological studies, analysing symptomatic and asymptomatic SCCE patients, would be beneficial in providing accurate quantification of disease burden. Other future research directions include exploring intracranial stenting for CCE revascularisation and cerebral intravascular lithotripsy.

The influence of gender on outcomes following transcatheter aortic valve implantation.

Objectives: This study aimed to compare gender-related differences in short- and long-term outcomes after transcatheter aortic valve implantation. Methods: Patients who underwent transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) from September 2017 to December 2022 were enrolled. The primary endpoint was 5-year all-cause mortality. The secondary endpoints were 30-day mortality and the incidence of post-procedural complication. Patients were separated according to gender before statistical analysis. To compare patients with similar baseline characteristics, we performed a propensity matching. Results: A total of 704 patients [females, 361 (51.3%); males, 343 (48.7%)] were enrolled. Compared to women, men had a higher incidence of smoking (40.5% vs. 14.7%, p < 0.001), diabetes (32.9% vs. 25.1%, p < 0.025), peripheral artery disease (35.8% vs. 18.3%, p < 0.001), and previous cardiac surgery (13.7% vs. 7.2%, p = 0.006) and a lower ejection fraction [56.6 (9.3) vs. 59.8 (7.5), p = 0.046]. Female patients were frailer at the time of the procedure [poor mobility rate, 26% vs. 11.7%, p < 0.001; CCI (Charlson comorbidity index) 2.4 (0.67) vs. 2.32 (0.63), p = 0.04]. Despite these different risk profiles, no significant differences were reported in terms of post-procedural outcomes and long-term survival. Propensity score matching resulted in a good match of 204 patients in each group (57.9% of the entire study population). In the matched cohort, men had a significantly higher incidence of new pacemaker implantation compared to women [33 (16.2%) vs. 18 (8.8%)]. The Kaplan-Meier 5-year survival estimate was 82.4% for women and 72.1% for men, p = 0.038. Conclusions: Female gender could be considered as a predictor of better outcomes after TAVI.

Learning three-dimensional aortic root assessment based on sparse annotations.

Purpose: Analyzing the anatomy of the aorta and left ventricular outflow tract (LVOT) is crucial for risk assessment and planning of transcatheter aortic valve implantation (TAVI). A comprehensive analysis of the aortic root and LVOT requires the extraction of the patient-individual anatomy via segmentation. Deep learning has shown good performance on various segmentation tasks. If this is formulated as a supervised problem, large amounts of annotated data are required for training. Therefore, minimizing the annotation complexity is desirable. Approach: We propose two-dimensional (2D) cross-sectional annotation and point cloud-based surface reconstruction to train a fully automatic 3D segmentation network for the aortic root and the LVOT. Our sparse annotation scheme enables easy and fast training data generation for tubular structures such as the aortic root. From the segmentation results, we derive clinically relevant parameters for TAVI planning. Results: The proposed 2D cross-sectional annotation results in high inter-observer agreement [Dice similarity coefficient (DSC): 0.94]. The segmentation model achieves a DSC of 0.90 and an average surface distance of 0.96 mm. Our approach achieves an aortic annulus maximum diameter difference between prediction and annotation of 0.45 mm (inter-observer variance: 0.25 mm). Conclusions: The presented approach facilitates reproducible annotations. The annotations allow for training accurate segmentation models of the aortic root and LVOT. The segmentation results facilitate reproducible and quantifiable measurements for TAVI planning.

A Case of Acute Right Coronary Artery Ostial Obstruction Six Days After Surgical Aortic Valve Replacement Requiring Emergent Coronary Artery Bypass Grafting.

Acute coronary artery obstruction after surgical aortic valve replacement (SAVR) is a rare but potentially life-threatening event that must be prevented. Here, we report a rare case of an 84-year-old woman who underwent SAVR with a 19-mm aortic bioprosthetic valve for severe aortic stenosis and who suddenly developed ST-elevation myocardial infarction six days after surgery as a result of right coronary artery (RCA) ostial obstruction. She experienced cardiogenic shock, and mechanical support devices were introduced; however, she underwent emergency coronary artery bypass grafting (CABG) to the RCA (#3) and survived. We were aware of the risk of RCA ostial obstruction intraoperatively but were unable to prevent it because blood flow was preserved in the early postoperative period. The present case is worth reporting because the patient developed fatal STEMI at a time when she would normally be considered for discharge. A major learning point from this case is that a coronary artery ostium that is patent immediately after SAVR may not be sufficient for patients considered at high risk of coronary artery occlusion.

Atypical Presentation of Coxiella burnetii Endocarditis: Diagnostic Considerations and the Importance of Keeping a Broad Differential.

Coxiella burnetii is a gram-negative bacterium associated with serious complications such as infective endocarditis. Early diagnosis and treatment can be difficult due to its nonspecific presentation and risk factors that include contact with farm animals or their byproducts. Here, we present an atypical presentation of infective endocarditis caused by Coxiella burnetii, where the patient had no risk factors, negative Duke criteria, and negative preliminary workup.

Left versus right ventricular pacing during TAVR and balloon aortic valvuloplasty: A systematic review and meta-analysis.

INTRODUCTION: While right ventricular pacing (RVP) is the conventional temporary pacing modality used for transcatheter aortic valve replacement (TAVR), this approach possesses inherent risks and procedural challenges. We aim to assess and compare the safety and efficacy of left ventricular pacing (LVP) and RVP during TAVR and balloon aortic valvuloplasty (BAV). METHODS: Following PRISMA guidelines, a comprehensive literature search was conducted in four databases from inception to December 15th, 2023. We included observational studies and clinical trials comparing LVP with RVP during TAVR and BAV procedures. Primary outcomes included short-term mortality, mortality due to cardiac tamponade, and procedural complications including bleeding, vascular complications, and cardiac tamponade. Secondary outcomes comprised procedure duration and length of hospital stay. RESULTS: Five studies involving 830 patients with RVP and 1577 with LVP were included. Short-term mortality was significantly higher in the RVP group (RR 2.32, 95% CI: [1.37-3.93], P = .002), as was the incidence of cardiac tamponade (RR 2.19, 95% CI: [1.11-4.32], P = .02). LVP demonstrated shorter hospital stays (MD = 1.34 d, 95% CI: [0.90, 1.78], P < .001) and reduced procedure duration (MD = 7.75 min, 95% CI: [5.08, 10.41], P < .00001) compared to RVP. New pacemaker implantation was higher in the RVP group (RR 2.23, 95% CI: [1.14, 4.39], P = .02). CONCLUSION: LVP during TAVR and BAV emerges a safer alternative to RVP, offering reduced mortality, hospital stays, and procedure durations.

Long-Term Outcomes of Mechanical versus Bioprosthetic Aortic Valve Replacement in Patients Under 50 Years Old: Meta-Analysis of Reconstructed Time-to-Event Data.

To compare long-term outcomes of mechanical versus bioprosthetic aortic valve replacement (AVR) in patients under the age of 50, we performed a study-level meta-analysis with reconstructed time-to-event data including studies published by December of 2023. The primary outcome was overall survival. Secondary outcomes included reoperation, major bleeding, and stroke. Five studies met our inclusion criteria with a total of 4245 patients (2311 mechanical, 1934 bioprosthetic). All studies were observational and the mean age of groups across the studies ranged from 38.2 to 43.0 years. The median follow-up time was 11.4 years (IQR, 6.9-15.0). Bioprosthetic AVR was associated with reduced overall survival and higher risk of all-cause death (HR, 1.170 [95% CI, 1.002-1.364], P=0.046), increased risk of reoperation over time (HR, 2.581, [95% CI, 2.102-3.168], P<0.001), decreased risk of major bleeding (HR, 0.500, [95% CI, 0.367-0.682], P<0.001), and decreased risk of stroke (HR, 0.751, [95% CI, 0.565-0.998], P=0.049) compared to mechanical AVR in patients under 50. In conclusion, for patients under the age of 50, bioprosthetic AVR is associated with increased mortality and risk of reoperation compared to mechanical valves. On the other hand, mechanical AVR is associated with an increased risk of major bleeding events and stroke. These aspects should be carefully considered during the selection of valve type in this age group; however, we should keep in mind that the statistically significant differences in the risk of all-cause death and stroke might not be clinically relevant (due to marginal statistical significance).

Early anticoagulation after aortic valve replacement with porcine bioprosthesis randomized control trial(ANTIPRO). 3 years follow-up.

BACKGROUND: Most evidence for anticoagulation in aortic bioprosthesis is centered on embolic events, bleeding and re-intervention risk. The effect of anticoagulation on hemodynamics has not been previously assessed. Our hypothesis was that patients with anticoagulation (AC) early after aortic valve replacement (AVR) with porcine bioprosthesis have better hemodynamics at 3 years of follow-up. METHODS: This is a follow-up evaluation of the ANTIPRO trial. All patients undergoing AVR with porcine bioprosthesis were consecutively recruited. The AC group received warfarin+aspirin and the non-AC(control) only aspirin. The primary outcome was mean gradient after 3 years of AVR and change in New York Heart Association (NYHA) class. Secondary outcomes were major and minor bleeding and embolic events. RESULTS: Of 140 participants in the study, 71 were assigned to the AC group and 69 to the control group. Mean age of the overall population was 72.4(SD: 7.1) years. Global euroSCORE was 7.65(SD: 5.73). At 3 years the mean gradient was similar between both groups (19.4(SD: 9.6 mmHg) and 18.6(SD: 8.2 mmHg) in the control and AC group respectively, p = 0.7). No differences in functional class at 3 years were found among groups. No differences were found among groups in the secondary outcomes. CONCLUSIONS: The addition of 3 months of oral anticoagulation to anti-aggregation treatment did not affect bioprosthetic hemodynamics nor functional class at years after AVR.

Prognostic value of brachial-ankle pulse wave velocity changes post-transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) offers a solution, especially for high-risk aortic stenosis (AS) patients. However, patient outcomes post-TAVR show variability, highlighting the need for reliable prognostic indicators. Brachial-ankle pulse wave velocity (baPWV), a measure of arterial stiffness, may predict outcomes post-TAVR. This study aims to explore baPWV's prognostic value in relation to all-cause mortality post-TAVR. This study prospectively enrolled 212 severe AS patients undergoing TAVR between September 2015 and December 2021, focusing on pre- and post-TAVR baPWV measurements to explore associations with all-cause mortality. Of the 212 patients (119 females, 93 males, mean age 85 years), post-TAVR baPWV increased significantly from 1589 ± 376 to 2010 ± 521 cm/s (p < 0.001). Aortic valve (AV) peak velocity and mean pressure gradient decreased, while AV area increased, indicating procedural success. Despite this, 88% of patients experienced an increase in baPWV, with higher pre-procedure AV peak velocity and mean pressure gradient identified as predictors of increased baPWV post-TAVR. Over 23 months, 29 patients (14%) reached the primary endpoint of all-cause mortality. Notably, changes in baPWV, rather than baseline values, were significantly associated with event-free survival (HR: 0.64 per 1SD increase, p = 0.009). The study highlights the prognostic value of baPWV changes post-TAVR in predicting patient outcomes. Elevated baPWV post-TAVR may reflect a beneficial adaptation to altered hemodynamics, suggesting the need for individualized patient evaluation and the integration of baPWV measurements into clinical practice for improved post-TAVR management.

A Comprehensive Evaluation of the NAVITOR Transcatheter Aortic Valve Replacement System.

Transcatheter aortic valve replacement (TAVR) has undergone significant advancements in the last two decades, expanding its indications and refining transcatheter heart valve (THV) and delivery system designs to improve procedural success and patient outcomes. This review focuses on the Navitor™ valve, a third-generation intra-annular Portico™ valve (Abbott Structural Heart, St Paul, MN, USA) designed to address TAVR complications, particularly paravalvular leak (PVL). We present an overview of the Navitor™ system, comparing it to the first-generation Portico™ THV in terms of THV design, key iterations and clinical outcomes. The Navitor™ THV introduces two key refinements-a protective outer sealing skirt and a more flexible delivery system. These enhancements have led to a significant reduction in 30 day PVL rates, from 6.3% with the first-generation Portico™ to 0% with the Navitor™ system. Additionally, the Navitor™ system exhibited lower rates of severe bleeding (27.3% versus 13.1%) and major vascular complications (5.8% versus 0.7%) compared with the first-generation Portico™. The Navitor™ valve represents a promising advancement in TAVR technology, with notable reductions in complications such as PVL, severe bleeding, and major vascular issues, compared with its predecessor. While further research is needed to assess long-term durability, these results underscore its potential benefits in enhancing patient outcomes and reducing complications. This review provides insights into the evolving landscape of TAVR technology and its quantifiable impact on patient care.

Retrograde Aortic Valve Migration During Transcatheter Aortic Valve Replacement for Aortic Regurgitation: A Case Report Highlighting the Importance of Prompt Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) Initiation.

Surgical aortic valve replacement (SAVR) is the recommended curative treatment for pure native aortic regurgitation (AR). However, some patients are not suitable for SAVR due to comorbidities or frailty. Transcatheter aortic valve replacement (TAVR) has been reported to offer a better prognosis than medical therapy in AR patients; thus, the use of TAVR for AR may increase in the future. However, the reduced calcification and annulus ring stiffness associated with TAVR may increase the risk of valve migration. Accumulating data on rescue measures in the event of valve migration is necessary. An 87-year-old female with a history of hypertension and persistent atrial fibrillation presented to our emergency department with dyspnea. The patient was diagnosed with congestive heart failure class IV, according to the New York Heart Association classification, necessitating urgent admission to our cardiac department. Due to the patient's high surgical risk (Society of Thoracic Surgeons (STS) score 9.17%, Euro2 score 9.55%, frailty 6), the heart team performed TAVR with a right femoral arterial approach. The patient was sedated, and pacing was initiated at 180 bpm. We placed an Edwards SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) #23 (-1 mL volume, with attached balloon). During the post-deployment procedure, the aortic valve migrated retrogradely into the left ventricle (LV). Despite the occurrence of severe aortic valve regurgitation, the patient's vital signs remained stable. Five minutes after the migration of the aortic valve, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. A second TAVR valve implantation was then performed. However, after the second valve implantation and the removal of the pre-shaped guidewire (Safari2 pre-shaped guidewire extra small, Boston Scientific, Marlborough, MA, USA), the migrated valve became stuck in the left ventricular outflow tract (LVOT) in a reverse position, resulting in severely limited left ventricular ejection. We increased the support provided by VA-ECMO, and surgical conversion to SAVR was performed without experiencing circulatory collapse. Surgical aortic valve replacement was initiated successfully, and withdrawal of the cardiopulmonary bypass (CPB) was performed without complications. The patient was extubated on the first postoperative day (POD), discharged from the ICU on POD 3, and transferred for rehabilitation on POD 27. In summary, the prompt introduction of VA-ECMO was important for avoiding complications and saving the patient's life following the retrograde migration of the TAVR valve.

20 Years of triple-valve surgery in the UK: demographic and outcome trends.

OBJECTIVES: To describe evolving demographic trends and early outcomes in patients undergoing triple-valve surgery in the UK between 2000 and 2019. METHODS: We planned a retrospective analysis of national registry data including patients undergoing triple-valve surgery for all aetiologies of disease. We excluded patients in a critical preoperative state and those with missing admission dates. The study cohort was split into 5 consecutive 4-year cohorts (groups A, B, C, D and E). The primary outcome was in-hospital mortality, and secondary outcomes included prolonged admission, re-exploration for bleeding, postoperative stroke and postoperative dialysis. Binary logistic regression models were used to establish independent predictors of mortality, stroke, postoperative dialysis and re-exploration for bleeding in this high-risk cohort. RESULTS: We identified 1750 patients undergoing triple-valve surgery in the UK between 2000 and 2019. Triple valve surgery represents 3.1% of all patients in the dataset. Overall mean age of patients was 68.5 ± 12 years, having increased from 63 ±12 years in group A to 69 ± 12 years in group E (P < 0.001). Overall in-hospital mortality rate was 9%, dropping from 21% in group A to 7% in group E (P < 0.001). Overall rates of re-exploration for bleeding (11%, P = 0.308) and postoperative dialysis (11%, P = 0.066) remained high across the observed time period. Triple valve replacement, redo sternotomy and poor preoperative left ventricular ejection fraction emerged as strong independent predictors of mortality. CONCLUSIONS: Triple-valve surgery remains rare in the UK. Early postoperative outcomes for triple valve surgery have improved over time. Redo sternotomy is a significant predictor of mortality. Attempts should be made to repair the mitral and/or tricuspid valves where technically possible.

Antithrombotic Therapy in Patients Undergoing Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) now represents the mainstay of treatment for severe aortic stenosis. Owing to its exceptional procedural efficacy and safety, TAVI has been extended to include patients at lower surgical risk, thus now encompassing a diverse patient population receiving this treatment. Yet, long-term outcomes also depend on optimal medical therapy for secondary vascular prevention, with antithrombotic therapy serving as the cornerstone. Leveraging data from multiple randomized controlled trials, the current guidelines generally recommend single antithrombotic therapy, with either single antiplatelet therapy (SAPT) or oral anticoagulation (OAC) alone in those patients without or with atrial fibrillation, respectively. Yet, individualization of this pattern, as well as specific case uses, may be needed based on individual patient characteristics and concurrent procedures. This review aims to discuss the evidence supporting antithrombotic treatments in patients treated with TAVI, indications for a standardized treatment, as well as specific considerations for an individualized approach to treatment.